CLUB INFO:

Club Name: ___________________________________________________
Address: _____________________________________________________
City: ________________________ State: __ Zip: _____-____
Telephone: (___)___-_____ Email: _________________________
Workout days and times: _________________________________________

SENSEI INFO:

Name: ________________________________________________________
Address:_______________________________________________________
City: ________________________ State: ___ Zip: _____-____
Telephone: (___)___-_____ Email: _________________________
FIRST DELEGATE

Name: ________________________________________________________
Address:_______________________________________________________
City: ________________________ State: ___ Zip: _____-____
Telephone: (___)___-_____ Email: _________________________
SECOND DELEGATE

Name: ________________________________________________________
Address:_______________________________________________________
City: ________________________ State: ___ Zip: _____-____
Telephone: (___)___-_____ Email: _________________________
THIRD DELEGATE

Name: ________________________________________________________
Address:_______________________________________________________
City: ________________________ State: ___ Zip: _____-____
Telephone: (___)___-_____ Email: _________________________
Mail to CJI 36 Gay Hill Rd. Uncsasville CT. 06382
With check for $30 payable to "C.J.I."                    CJICM1(Rev09/2004